Stalled funding, policies of 2018 pose continuing challenges to infectious disease responses ahead

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A year that started with a shutdown of the U.S. government is ending the same way, demonstrating ongoing instability in American policy, funding and global health leadership. At the same time, from events dividing the ranks of global HIV responders, to the first Ebola outbreak fought in a war zone, the year has highlighted needs for strengthened and science-based efforts to control and combat infectious diseases worldwide.

The Global AIDS Response: Results of the PARTNER 2 study reported at AIDS 2018 in Amsterdam delivered final validation that “U = U” — that when treatment has suppressed HIV to undetectable levels, the virus is not transmitted. With that comes further impetus for accelerated efforts to ensure that all people living with HIV worldwide have access to effective and consistent treatment. Congress acknowledged the pivotal role the U.S. President’s Emergency Plan for AIDS Relief must continue to play in reaching that goal, with a swift and bipartisan renewal of the program’s authorization. Finally, the Senate proposed a $50 million funding increase for PEPFAR — the first boost for the program in a decade.

That fate of that funding, however, remains in question in the absence of a budget agreement. In the meantime, the Trump administration’s expanded “global gag rule,” barring funding for HIV and other disease responses from overseas organizations that provide comprehensive reproductive health services continues to divert dollars from programs reaching women and girls, as well as other marginalized populations worldwide.

Against that backdrop, the strength and stability of internationally supported and local, community-driven HIV responses remain critical, and increasingly pivotal to the development of sustainable health systems. This year, however, also has seen UNAIDS, which counts as part of its mission “speaking out in solidarity with the people most affected by HIV in defense of human dignity, human rights and gender equality,” described as  “a predators preyground,” in the wake of an external investigation of sexual harassment and assault within the organization. At the same time, the selection of San Francisco and Oakland as hosts for AIDS 2020 — the next conference set to bring HIV scientists, philanthropists, policy makers and community members from around the world together — in the midst of U.S. policies hostile to immigrants, residents of muslim majority countries, as well as to people who have earned money through sex work or used illegal drugs — threatens to divide the HIV advocacy community. A planned alternate and concurrent  HIV 2020 Mexico City meeting is among the responses.

Tuberculosis: The House of Representatives proposed a $41 million increase for USAID’s TB program in 2019, but the fate of that proposal remains in limbo. A United Nations General Assembly high-level meeting in September focused on tuberculosis, with a declaration endorsed by governments around the world committing to finding and treating finding and treating 40 million people sick with tuberculosis, to preventing the infection in 30 million people by 2022. The declaration recognized the growing threat posed by drug-resistant strains of disease,  including with a commitment to develop shorter, more effective, oral treatment regimens. Three months earlier, South Africa health officials had already set new treatment guidelines for treating drug-resistant disease, replacing painful injections that brought irreversible side effects to many patients with bedaquiline, one of the two newest medicines that while proven effective has remained out of reach for most patients. The World Health Organization had followed suit with a heads up that new treatment guidelines recommending the exclusion of the most toxic drugs, and the inclusion of the newest, would be finalized by the end of the year. It remains, however, to be seen when other countries will adopt the guidelines.

Ebola: The Trump administration announced plans to cut money from global and domestic health security programs in May, on the same day the  Democratic Republic of Congo announced its second outbreak of the virus in a year. With a swift international response and the deployment for the first time of an investigational anti-Ebola vaccine developed in the waning days of the West Africa Ebola crisis, the outbreak, in the northwestern region of the country ended in three months. It was followed swiftly, however, by recognition of the current outbreak, which continues across active war zones, and near neighboring Uganda, Rwanda and South Sudan, and is expected to continue well into the next year.

The opioid crisis: The nearly half-century U.S. “war on drugs” finally took an evidence-based turn this year, with policymakers’ passage of the SUPPORT Act demonstrating awareness of infectious disease impacts of the current opioid use epidemic, and both the needs and opportunities it offers for improved surveillance of related illnesses. The acknowledgement, reflected in the legislation, that approaches to substance use disorders and associated infections must be comprehensive, has yet to be reflected in the routine implementation of harm reduction interventions, needle and syringe programs and safe injection sites, in U.S. federally funded global or domestic programs.

Stay tuned . . . While this year ends as the last began, with political polarization, a standoff, and a standstill, it has also seen change, with the confirmation of a new Secretary of Health and Human Services at the start of the year, and continuing with leadership overturn across the administration, including at the State Department and the Centers for Disease Prevention and Control. On Jan. 3, the 116th Congress will bring more change, with new members and leaders of House and Senate committees addressing global health policies and funding. Science Speaks will follow developments.

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